1 Primary care screening for early childhood problems and caregiver depressionElise Fallucco, MD Child and Adolescent Psychiatrist, Board-Certified Physician Scientist, Nemours Center for Healthcare Delivery Science May – June 2014

2 Gratitude and DisclosuresMary Margaret Gleason, MD, FAAP; Tulane Institute of Infant and Early Childhood Mental Health Mini Tandon, DO; Washington University Department of Psychiatry, Director, Preschool Clinic at BJCBH Emma Robertson-Blackmore, PhD; Dept Psychiatry, UF-Jax Steven Cuffe, MD; Chair, Dept of Psychiatry, UF-Jax Amanda Lochrie, PhD, ABPP and Holly Antal, PhD, ABPP; Nemours Children’s Clinic, Div Psychology Chelsea Kozikowski, BA; Carolina Bejarano, BS; Robin Landy Add PCP champions here, too

3 Overview I –Why screen for early childhood problems and caregiver depression? II – How to screen using the Early Childhood Screening Assessment (ECSA) III – Interpreting the ECSA Case examples “ABCs” for evaluating preschool behavior problems IV – When/where to refer

4 I - Why screen for early childhood problems?They are common and cause impairment Child care expulsion, family stress and parental guilt, increased risk of child maltreatment, family suffering Imagine overall + screen 7-10% depending upon setting based on PSC (Little and Jellinek ) Family stress – lack of sleep, parental self-blame/conflict, less opportunities to use extended family/friend support Egger H, Angold A. J. Child Psychol. Psychiatry

5 Why screen for early childhood problems?The problems persist Majority of kids with emotional/behavioral problems will continue to have impairment up to 4 years later If identified and treated, problems respond to appropriate interventions Parent-Child Interaction Therapy Parent Management Briggs-Gowan M, Carter A. Pediatrics Hoagwood K, Burns BJ, Kiser L, Ringeisen H, Schoenwald SK. Psych Serv. 2001 Lavigne J, Gibbons R, Christoffel K, Arend R. Journal of Am Acad Child & Adolesc Psychiatry Lenze SN, Pautsch J, Luby J. Depress. Anxiety. 2011

6 Why screen for caregiver depression?Depressive symptoms common among moms of young children (6-17%) Depression negatively affects child development higher risk of cognitive, social/emotional developmental delays, behavioral problems, accidents, poor safety practices Maternal depression persists If identified, depression responds to treatment Likewise, mat depression is common, impacts child devt, and is underrecognizes Chung E. Pediatrics. 2004; Giles L, Davies M, Whitrow M, Warin M, Moore V. Pediatrics. 2011; Horwitz SM, Briggs-Gowan MJ, Storfer-Isser A, Carter AS. J Women’s Health. 2009; Kahn R. Pediatrics. 1999; McLennan J. Pediatrics. 2000; Olson A, Dietrich A, Naspinsky D, et al. J Dev Behav Pediatrics. 2005; Olson A. Pediatrics

7 These problems that impact child development are hiddenParents reluctant to ask for help for children… Majority of concerned parents do NOT independently express concerns to PCP about child behavior/mood Or for their own depressive symptoms Mistrust? fear of judgment Surveillance (vs. screening)  low detection PCPs detect only a minority of children with serious e/b problems (20% sensitivity) PCPs under-identify mothers with high-levels of depressive symptoms (29% sensitivity) Heneghan AM. Pediatrics Lavigne JV, Binns HJ, Christoffel KK et al. Pediatrics Sheldrick RC, Neger EN, Perrin EC. J Dev Behav Pediatrics Weitzman CC, Leventhal JM. Curr Opin Pediatr. 2006

8 Screening improves early identificationAAP and Bright Futures psychosocial/behavioral assessment at well-visits, surveillance re: parental social-emotional well-being Screening improves early identification Universal screening Normalizes discussion of mental health issues Gives caregivers a place to express concerns PCP Surveillance Universal screening % of HIGH RISK preschoolers detected 20.5 % 86 % % depressed moms detected 29% 92-97% Gleason M, Zeanah C, Dickstein S. Infant Mental Health Journal. 2010; Heneghan AM. Pediatrics. 2000; Lavigne JV, Binns HJ, Christoffel KK et al. Pediatrics Arrol B et al, Ann Fam Med, 2010

9 II – How to screen Early Childhood Screening Assessment (ECSA)40-item, parent report checklist for kids 1 ½ - 5 years old Child emotional and behavioral symptoms Parental concerns about symptoms/behavior (+) Parental distress and depression 3-point rating scale Takes 5-10 mins to complete, 1-2 minutes to score Validated (86% sensitive, 83% specific) Interpreting the ECSA Child score = sum of items 1- 36; 18+ elevated risk Caregiver score = sum items 37+38; 2+ concerning Compared with the DIPA: Diagnostic Interview for Preschool Age Gleason M, Zeanah C, Dickstein S. Infant Mental Health Journal

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11 Workflow Provide assessment using ECSA If <18: Negative screenPositive screen Child score: Sum Items 1-36 Interpret findings: Target area(s) of concern & determine severity and persistence Determine whether to refer for further assessment Interpret findings & acknowledge importance of screening Assess for any child safety concerns Caregiver score: Sum Items 37-38 If 2+: Positive screen

12 III – Interpreting ECSA Case #1 : Tommy, 4 years 1 month oldCHILD score = 14: “2”: argues with adults, is always “on the go” “1”: easily distracted, doesn’t listen to adults, fidgets, is clingy, runs around, interrupts, disobedient, hard time falling asleep “+” : argues with adults, doesn’t listen to adults, disobedient Caregiver seeks help with managing oppositional behavior CAREGIVER depression score = 0 Caregiver stress = 2 “1”: too stressed to enjoy this child, get more frustrated than I want to with child

13 Evaluating negative screensDiscuss screen results with family and child Address parental concerns and “+” What are you most concerned about? Reassure, provide anticipatory guidance Provide resources Incredibleyears.org, healthychildren.org At next visit, reassess risk functioning, and symptoms

14 THE ABC’s A = A good nights sleep Sleep HygieneAsk: What time does your child go to sleep? Do they sleep independently? What is your routine? How many hours of sleep does your child get most nights? Do they sleep in their own bed, all night, and without waking up? Educate parents on an appropriate night’s sleep

15 THE ABC’s B = Body (What is going into it?) Health HygieneDoes your child eat breakfast, lunch and dinner every day and have up to 2 snacks? What do they drink during the day? Are they picky eaters? Do problem problems occur at mealtime?

16 THE ABC’s C = Chart it BehaviorCreate a visual schedule and structure to the day Encourage parents to create a behavior chart to track a few behavior patterns with regard to problems with sleeping, eating, and behavior throughout the day and use stickers to reinforce compliance with routine

17 Case #2 : Josh, 4 years 7 monthsEx-34 week boy w/ hx Early Steps, constipation Mom’s complaint: “He is very high energy.. Very busy” CHILD score = 24: “2”: easily distracted, doesn’t listen to adults, fidgets, hard time paying attention, interrupts, always “on the go”, disobedient, might wander off “1”: loses temper, argues with adults, trouble interacting with kids, worries, is too interested in sexual play, runs around, hard time falling asleep, too friendly with strangers MOTHER depression score = 0 Mother stress = 2 “too stressed to enjoy child”, “get more frustrated”

18 Evaluate positive child screenExplore symptoms and functional impairment What bothers you the most? Assess safety issues Rule out trauma, impulsivity (running away) Address environmental issues that may exacerbate disorder Divorce, marital conflict, sibling, move Positive screen is not diagnostic; warrants follow-up Identifying and acknowledging challenges is helpful Determine whether/where to refer Trauma – who takes care of Tommy when you are not around? Have you ever had any concerns about his safety aroudn this caregiver, any inappropriate touching or hitting? How fo you address boundaries with your child

19 Case #3 : Alexis, 3 years 3 monthsCHILD score = 10: “2”: doesn’t listen to adults, argues with adults, runs around, on the go, disobedient MOTHER depression score = 1-2: “1 or 2”: feel down, depressed or hopeless Mother Stress = 4: “2”: too stressed to enjoy this child, more frustrated than I want to with this child’s behavior

20 Evaluate positive maternal screenExplore symptoms, functional impairment Empathize, normalize Discuss impact on child Seek family and community support Encourage caregiver to seek help Would you be willing to get help if you knew it would help your child? (oxygen mask) You are your child’s world, your child’s everything, you DESERVE help

21 IV – When/Where to referFor “positive” cases of child emotional/behavioral problems that cannot be monitored in primary care Cross reference the list of local providers who assess and treat preschoolers (see handout) For “positive” cases of caregiver depression Refer to caregiver’s PCP or OB/GYN or refer to list of local providers who care for mothers/fathers

22 Summary Problems that impact early child development are common, persistent, and underidentified Systematic screening increases rates of identification and should improve early intervention Screen all children at well-visits for early childhood problems using the ECSA

23 Research angle Learn more about your practice’s experience with universal screening Review and sign consent form in folder Complete PCP survey Determine frequency of caregiver-reported problems in our population Ask caregivers to share an anonymous, de-identified copy of ECSA with study team

24 Addendum: Logistics of ScreeningInform families at check-in with “Letter to Families” Ask parent to complete ECSA in the waiting room Staff scores ECSA (orient staff to ECSA) PCP reviews score before entering the room 96127 – bill for screens If parent consent, de-identified copy of ECSA placed in study folder